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Hospitals as learning organizations: fostering innovation through interactive
learning
Abstract
The paper aims to provide an analytical understanding of hospitals as “learning
organizations”. It further analyses the development of “learning organizations” as a way
to enhance innovation and performance in the hospital sector.
The paper pulls together primary data on organizational flexibility, innovation and
performance from 95 hospitals in Portugal, collected through a survey, interviews to
hospital’s boards and a nominal group technique with a panel of experts on health
systems.
Results show that a combination of several organizational traits of the learning
organization enhances its capacity for innovation development. The logistic model
presented reveals that hospitals classified as “advanced learning organizations” have
five times more chance of developing innovation than “basic learning organizations”.
Empirical findings further pointed out incentives, standards, and measurement
requirements as key elements for integration of service delivery systems and expansion
of the current capacity for structured and real-time learning in the hospital sector.
The major implication arising from this study is that policy needs to combine
instruments that promote innovation opportunities and incentives, with instruments
stimulating the further development of the core components of learning organizations.
Such a combination of policy instruments has the potential to ensure a wide external
cooperation through a learning infrastructure.
Keywords
Hospital; Health services; Learning organization; Innovation; Performance.
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Article Type
Research Paper
1. INTRODUCTION
Hospitals in Portugal, as well as, across Europe, are currently facing several challenges,
including the ageing population, the increasing burden of chronic diseases related to risk
factors and the expansion of health care options by new technologies. Moreover, the
current economic crisis has resulted in bothnegative implications on the availability of
resources, as well asa positive impact on the demand for health services. These
circumstances are increasingly adding pressure to performance improvement of the
hospital sector (Morgan, D., Astolfi, R., 2013).
It is widely assumed that these currentchanges in the economic environment might be
described by the concept of ‘the learning economy’ (Lundvall, B-Å, Johnson, B., 1994).
It argues that besides the increasing use of knowledge in the economy, the knowledge
itself becomes obsoleteat a faster pace. While mechanisms for knowledge creation and
diffusion have significantly advanced, the access and the application ofsuch knowledge
have not keep up the same pace. The result is an important gap between existing
evidence and daily practice in the hospital sector. This calls for increased focus on
learning capacities of hospitals to make the best use of knowledge in terms of
innovation development (Nembhard, I.M., Tucker, A.L., 2011). In this paper, learning
refers to the acquisition of new skills and competences in order to achieve individual or
organizational goals (OECD, 2011; Ferlie, E. B., Shortell, S. M., 2001).
As hospitals are facing an increasing turbulent environment, it become imperative to
support learning conditions within hospitals in order to tackle current and emergent
challenges (Edmondson, A. C., 2004).
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The recognition that knowledge and learning are key drivers of innovation and
performance has been a major breakthrough in management thinking. It has opened new
perspectives on management towards learning processes across different sectors of the
economy.
These research traditions, building on the work of sociology and economy, have been
summarised by Rogers, which have focused on linkages between the innovation
developers and adopters (Rogers, 1995). However, the knowledge based
approacheshave radically redefined both innovation developmentand dissemination in
terms of knowledge creation and dissemination.The absorptive capacity for new
knowledge has been introduced as a non-structural factor of innovation including
‘learning organisation’ values and goals, organization’s existing knowledge base,
promotion of knowledge dissemination within and outside the organisation (Argote, L,
2011).
Such focus on learning as part of enhancing organizational flexibility may be traced
back to the theoretical developments by Kanter (1983) and Rogers (1995). The main
argument of these authors is the need of organizations to enhance the capacity to
transform themselves in a continuous way. Such stream of literature has led to the
concept of the learning organization, combining different disciplines, such as total
quality management and organisational learning (Mulgan, G., Albury, D., 2003).
The management literature has pointed out the relevance of establishing ‘learning
organizations (Senge, P; 1990). Here, the organizational structure will have a major
effect on the rate of learning that takes place. Other factors include human resources
development, new organizational forms and external collaboration networks (Fleuren,
M., Wiefferink, K., Paulussen, T.; 2004).
4
Most managers in the hospital sector recognized the importance of improving learning
in their organizations in order to achieve quality improvement (Dean, B., 2002).
Therefore, it’s necessary not only to clarify the concept of learning organizations, but
also clarify to which extent hospitals can be classified as learning organizations.
Hospitals have been described as complex adaptive systems (Plsek, P., Greenhalgh, T.,
2001; Anderson, R. A., McDaniel Jr, R. R., 2000). Taking into account the principles
and resources supporting a learning environment, makes it possible for hospitals to take
full advantage of local knowledge in generating continuous improvements (Best et al,
2012). Indeed, recent empirical developments by the Institute of Medicine have
redefined the health sector as a learning health care system, which collect data from
daily activities and facilitate the use of scientific evidence to improve care, in a
continuous way (Institute of Medicine, 2011). The learning health care systems will
require the capacity to manage information-intensive work flows, with significant
potential to fill major knowledge gaps on health care costs, the benefits and risks of
specific drugs and clinical procedures (Greene SM, Reid RJ, Larson EB., 2012; Davies,
H. T., Nutley, S. M., Mannion, R., 2000; Crites, G. E et al, 2009).
The capacity of health care systems to learn has been
Health care has lagged far behind many other industries in harnessing the capabilities of
IT to improve services, knowledge, communication, outcomes, quality, and efficiency.
Given the complexity of modern medicine, it is inevitable that IT will play an ever
increasing role in improving health care quality. As noted by the IOM's Committee on
Quality Health Care in America, “Information technology must play a central role in the
redesign of the health care system if a substantial improvement in quality is to be
achieved over the coming decade.” To make significant progress, a major re-
engineering of the health care delivery system is needed, which requires changes in
technical, sociological, cultural, educational, financial, and other important factors.
Ways That Information Technology Can Reduce Errors
5
Information technology can reduce the rate of errors in three ways: by preventing errors
and adverse events, by facilitating a more rapid response after an adverse event has
occurred, and by tracking and providing feedback about adverse events. Data now show
that information technology can reduce the frequency of errors of different types and
probably the frequency of associated adverse events.7-18 The main classes of strategies
for preventing errors and adverse events include tools that can improve communication,
make knowledge more readily accessible, require key pieces of information (such as the
dose of a drug), assist with calculations, perform checks in real time, assist with
monitoring, and provide decision support.
Bates, David W., and Atul A. Gawande. "Improving safety with information
technology." New England journal of medicine 348.25 (2003): 2526-2534.
World Health Organization (WHO) Patient Safety established the Information
Technology for Patient Safety Expert Working Group to examine the role of
Information Technology (IT) in improving patient safety in healthcare. The Working
Group included representatives from high-, middle- and low-income countries with
expertise from clinical medicine, academia, government, health services management
and industry. This report by the Working Group provides an overview of the interplay
between IT and issues of patient safety in healthcare, maps out the boundaries of
knowledge in this area and makes recommendations for future research and
development. It builds on a recent systematic literature review commissioned by the
English National Health Service (NHS) Connecting for Health Evaluation Programme,
which included a review of research papers from across the world.
Huckvale, Christopher, et al. "Information technology for patient safety." Quality and
Safety in Health Care 19.Suppl 2 (2010): i25-i33.
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The purpose of this study is to explore the concept of learning organization in the
hospital sector in Portugal. The paper has three main objectives: explore the relevance
of knowledge and learning, assess the impact of learning organizations in innovation
capacity and identify the major mechanisms that enhance learning organizations in the
hospital sector.
2. CONCEPTUAL FRAMEWORK
The study builds on the approach by Lundvall of a national system of innovation as a
social system through a combination of evolutionary and institutional theorising.
Innovation is analysed as the outcome of cumulative causation in learning through
routine activities of production, distribution and consumption (Lundvall, B.-Å.; 1992).
This approach has been widely used in academic contexts, as well as a framework for
innovation policy-making (Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., &
Kyriakidou, O., 2004).
Within a socio-technical perspective, this framework shifts the focus from technological
to organisational innovation. The analytical distinction between technical and
organizational innovation is particularly important for two major reasons. Firstly, the
organizational structure of hospitals has a major impact on how innovation happens.
Secondly, such distinction makes it possible to link organizational and technological
innovation to organizational performance. Indeed, a series of empirical studies have
demonstrated that organisational changes are the key to transform innovation into
7
economic results (Gjerding, A.N., 1996; Leonard-Barton, D., 1988). This conceptual
model includes the variables of learning organization, innovation and performance.
Learning Organizations
The degree of learning organization denotes the way an organization is structured and
the routines followed will have a major effect on the rate of learning that takes place.
The basic idea is that the appropriate institutional structures may improve knowledge
production in terms ofcompetence building based on daily activities. The move towards
learning organizations is reflected in changes both in the firm’s internalorganization and
in inter-firm relationships. The choice of this definition is based upon the DISKO
researchers' concept of society as a learning economy (Lundvall, B-Å, Johnson, B.,
1994). Therefore, this study use the DISKO survey with questions aimed at pointing out
some organizational attributes, which are implicitly considered as an organization’s
ability to learn and evolve when faced with new challenges (Gjerding, A.N., 1996).
The survey measured the incidence of an array of organizational dimensions, which all
directly or indirectly refer to contemporary theories dealing with innovation and
flexibility in organizations: Cross occupational work groups, integration of functions,
softening demarcations, delegation of responsibility and self-directed teams are
empirical indicators, referring to Kanter’s (1982) theory of integrative organization
6
and
Burns and Stalker’s organic organizations (1994).
“Quality circles” and “proposal collection systems” are indicators of Quality
management (TQM) and Knowledge Management (Nonaka, I., Takeuchi, H., 1995).
“Tailored educational system and “educational planning” indicate human resources
development and cooperation with external actors refer to innovation as an interactive
process (Gjerding, A.N., 1996).
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The surveyed hospitals were classified in three groups according to the learning
organization index:
• Basic learning organization – hospitals which introduced zero to four of the
dimensions
• Moderate learning organizations- hospitals with five to eight different new
dimensions
• Advanced learning organizations- hospitals with more than nine new
dimensions.
Innovation
The study defines innovation as the implementation of a new or significantly improved
product/ service or process (OECD, EUROSTAT; 2005). The study takes a broader
understanding of innovative performance encompasses indicators related to the different
stages of these developments from idea creation to the introduction of new products and
services.Previous research has formally described, operationalized and empirically
analysed the different modes of innovation performance in the health sector (Kimberly,
J. R., Evanisko, M., 1981; Salge, T.O., Vera, A., 2009). Building on these studies and
taking into account the review of Fosfuri and Tribó (2008), innovation performance was
measured as the ratio of product, services or process innovation during a period of two
years previous to 2007. For robustness purposes, the analysis was also performed with a
different measure of innovation performance as a dummy variable which equals one if
the hospital had introduced a product, service and process innovation over a two-years
period and zero otherwise.
Performance
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Finally, the conceptual model includes the variable of hospital performance. While, the
ultimate goal of hospital care is to provide better health, other intermediate
administrative and clinical measures of both process and outcome may be considered.
(Freeman, 2002; Veillard, J., Champagne, F., Klazinga, N., Kazandjian, V., Arah, O. A.,
& Guisset, A. L., 2005). Therefore, hospital performance was measured by a set of five
indicators covering three dimensions, including “service quality” (rate of hospital re-
admissions within 15 days), “operational efficiency” (proportion of outpatient surgery
in the total number of surgeries and average length of hospital stay) and “financial
efficiency” (hospital net profit, proportion of extraordinary hours in the total staff
costs). The set of indicators was weighted to obtain a relative value of organizational
performance, which was defined by the National Coordination of Hospital
Commissioning (2008). These different dimensions of performance are interdependent
and should be simultaneously assessed within a multidimensional approach.
3. METHODS
A mixed methods design was used to explore the relationship between learning
organization and innovation in the hospital sector. The study systematically integrates
multiple forms of quantitative and qualitative data.
The research takes the approach of connecting data. This integration involved data
analysis from a quantitative survey on organizational flexibility and innovation with the
existing database on hospital performance. These data was further used to inform the
subsequent qualitative data collection, including the content and structure of the
interview. It was also used to determine the most appropriate participants with which to
explain the mechanism behind the quantitative results. This way it merges quantitative
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and qualitative data to develop a more complete understanding of a problem, to
compare, validate and triangulate results.
Quantitative Survey
Primary data was collected through a survey in order to determine the level of
organizational flexibility and the innovation rate of hospitals in 2007. It was used a
revised version of the DISKO Survey, which was developed by the Danish Research
Unit for Industrial Dynamics (DRUID). This survey is based on the search for
“organizational traits” related to organizational capacity to react and evolve when faced
with unstable environments.While the DISKO survey has been widely applied in the
manufacturing sector, it has not been previously used in the hospital sector. Therefore,
specific adjustments were made to the instrument in order to make it applicable to the
health sector. The revised survey excluded questions related to external competition due
to the fact it doesn’t apply to hospitals from the public sector in Portugal. Further
reliability and validity tests were performed on the instrument before the survey was
conducted, given that the initial instrument was explicitly altered in order to consider
specificities of the health sector. Following the revision of the survey by two experts on
health services research, the comprehensibility of the revised survey was tested on 6
hospital administrators who had not been included in the study group and their opinions
were used to prepare the final version of the survey.
The DISKO survey was translated into Portuguese by the researchers and revised by an
expert in the English language whose native language is Portuguese. Finally, it was
translated back into English by an independent translator who had not seen the original
questionnaire, for quality assurance.
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Each questionnaire consisted of 80 questions grouped in four sections, including work
organisationand management; work content and the demand for qualifications;
innovation in terms of new products services and processes; and level of external
cooperation. The paper-survey was submitted by post mail to a national sample of 136
hospital boards, listed from the official list of hospitals from Portuguese public sector.
A total number of 95 administrators from hospital boards reply to the survey during a
period of three months, corresponding to response rates of 70%, which is higher to the
rate of response on the first DISKO survey, which was 48% (Gjerding, A.N., 1996)
.All
survey responses were tracked using a unique login, which was linked to the particular
hospital in a master list, accessible only to the research team. The data from hospital
performance was further collected through the National Coordination of Hospital
Commissioning for each respondent hospital (2008).
The database referred to above has wider purposes than those presented in this study.
However, this paper only uses and presents the questions and data relative to learning
organization and innovation in the Portuguese hospital sector (Dias, C., Escoval, A.,
2012).
The data was submitted for statistical analysis in order to determine correlations
between the level of learning organizationand innovation. The bivariate correlation and
partial correlation were controlled for possible confounding variables (correlation
Pearson's R). The partial correlations enable variables that increase, decrease or
eliminate the relationship between the two initial variables to be revealed. An analysis
of cases through analysis of clusters and analysis of variance (One-Way ANOVA) was
further performed. The analysis of clusters detected homogeneous groups of data based
on quantitative information on variables. Finally, the binary logistic regression was used
to test the predictive capacity of the degree of learning organization on innovation.
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Interaction effects were also tested between innovation, performance, size and
specialization level. No significant differences were identified. In all cases, the level of
significance was set at 0.05. All statistics were calculated with SPSS version 15.0
(SPSS Inc., Chicago, IL, USA).
Interview study
The qualitative component of the study was aimed to develop a betterunderstanding of
the key processes involved in the development of learning organizations towards
innovation development.
A purposive sampling of the surveyed hospitals was undertaken to include a range of
hospitals with different characteristics of learning organizations based on the
quantitative data. The selected hospitals included two advanced learning organizations,
two moderate learning organizations and one basic learning organization. Semi-
structured and face-to-faceinterviews were undertaken with ten administrators of
hospital boards, with the focus on their views of the relationship between learning and
innovation, as well asthe major drivers of learning organizations.The interviews lasted
approximately two hours, were recorded and further transcribed.
The content analysis of the interviews was performed by using a grid of categories
framed within the different themes and context units of learning organizations. Building
on the qualitative analysis of the interviews' content, a statistical analysis was further
performed. A comparative assessment of the content based on the frequency analysis of
the main events into subcategories was developed. The analysis was carried out taking
into account the number of analysis units shown in subcategories and its significance.
Nominal Group Technique
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The third phase of the research included a qualitative study using the nominal group
technique. This technique was performed in order to consensualize the major findings of
the relationship between learning organizations and innovation based on the statistical
analysis of data surveys and content analysis of interviews.
The group included fifteen experts on health system performance assessment, hospital
administration, financing, information system and human resources development.A
modified nominal group technique was applied by introducing evidence for discussion
in a stepwise way before voting. The use of votes by the experts was particularly
relevant to overcome an unequal representation of different opinions. Through this
technique, the group of experts reached consensus on the major mechanisms for the
development of learning organizations in the Portuguese hospital sector. Such
integration of the three research phases, including both qualitative and quantitative data,
contributed to a detailed picture of the relationship between innovation and learning
organizations in the hospital sector.The database included other variables which are not
referred in this paper. All data collected refers to 2007.
4. RESULTS
Aims of innovation development
Performance improvement is considered as the major aim of innovation development by
60%of the total number of surveyed hospitals. Improving quality and flexibility, as well
asexternal cooperation, are also quoted as an aim of innovation by more than half of the
hospitals. Finally, knowledge creation and transfer is seen as an important aim by 30%
of the hospitals. However, it should also be noted that 25% of the total number of
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hospitals says that enhancing the knowledge base of the organization is of minor or no
importance.
Building on these results, a key issue is whether and to what extent the aims of
innovation represent common latent factors with multiple dimensions. The factorial
analysis uncovered two latent factors as aims for innovation development, as presented
in Table 1. The first factor covers specific aims such as the ability to strengthen and
renew knowledge and know-how, innovation development and adaptation to the
external environment. This factor explains 45% of the variation in responses. The
second factor corresponds to effectiveness and internal coordination,explaining 33% of
the variation in responses.
ADD TABLE 1
Clusters of learning organizations
The paper further examines if the aims for innovation by hospitals might vary according
to specific characteristics. Figure 1 shows that the aims for innovation development
vary according to the hospital size and level of specialization. While the big and
specialized hospitals give more importance to innovation and knowledge, the small and
less specialized hospitals are almost exclusively focused on effectiveness.
ADD FIGURE 1
Building on these initial findings, further empirical distribution of observations along
the additive index of learning organizations might reveal major characteristics of the
relationship between innovation and learning. Therefore, thestudyquestions whether
15
organizational structure and practices complement each other, as well as, enhance
innovation performance in a cumulative way. Such complementarities might reflect
‘bundles’ of organizational mechanisms supporting each other.
By grouping all the organizations according to the index of learning organization
development, 27% of total hospitals were situated in the basic category, 44% in the
moderate and 28% in the advanced category.
Table 2 shows the major factors that are relevant in explaining the differences in
innovation and performance across the three groups. “Advanced learning organizations”
show a high rate of innovation with a mean of 6.9 (3.4). In fact, this innovation rate is
four times higher than the cluster of “basic learning organizations”, with a mean of 1.6
(2.3). Furthermore, the level of performance of the cluster of “advanced learning
organizations” is the highest with a mean of 9.2 (6.0). Similarly, this level of
performance is two times higher than the performance of the cluster of “basic learning
organization”, with a mean of 4.8 (1.9).
ADD TABLE 2
Examining the relationships between learning organizations and innovation, the
organizational flexibility and external cooperation emerge as the two major factors. The
results point out significant differences of flexibility across the different levels of
learning organizations, ranging from a mean of 5 (0.9) to 6.4 (1.0). Regarding external
cooperation, the group of “advanced learning organizations” has more than double, the
level of external cooperation, with a mean of 0.7 (0.2), compared to the “basic learning
organizations” with a mean of 0.3 (0.16).
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The impact of learning organizations on innovation performance
The categories representing different levels of learning organizations were tested in a
logistic model with innovation as a dependant variable, and controlling for organization
size and level of specialization. As table 3 reveals, the hospitals in the cluster of
“advanced learning organizations” have five times more chance of developing
innovation than “basic learning organizations”. Similarly, the innovation development
in the cluster of “moderate learning organizations“is two times higher than the basic
one.
ADD TABLE 3
The content analysis of the interviews further revealed significant differences in terms
of the dynamic of learning processes across the different departments of hospitals. The
cluster of “basic learning organizations” shows a focus on performance, neglecting
knowledge creation and dissemination within the hospital. The learning processes are
mainly restricted to standard training courses on specific clinical procedures. The cluster
of “moderate learning organizations” recognizesthe dissemination of knowledge as a
major driver of innovation and performance improvement. Therefore, several
mechanisms are in place to promote teamwork and learning across departments. Finally,
the “advanced learning organizations”consider both knowledge creation and
dissemination as a major goal of the hospital. Besides enhancing learning across
different department, they put particular focus on external collaboration with
universities. Furthermore, such external collaboration networks go beyond the health
sector to include other sectors, particularly biomedical and information technology
industries.
17
Based on the data from the survey and interviews, the expert panel identified the major
mechanisms to enhance learning organizations in the hospital sector. Three key
mechanisms were particularly highlighted: Human resources development aligned with
the organizational strategy (26% of responses), solving daily problems in work teams
(31.60% of responses), and cooperation with other organizations (42.13% of responses).
Furthermore, the expert panel pointed out that current efforts to enhance innovation
reflectsa shift from formal and isolated mechanisms of professional development, as for
example standard courses, to informal mechanisms based on team work and external
cooperation, well integrated into daily work.
5. DISCUSSION
On the basis of theoretical considerations, empirical results show that innovation and
knowledge creation are two sides of the same coin. On one side, it is true that ‘learning
organizations’ are more apt to mobilize and apply different sources of knowledge for
innovation development. On the other side, it is also true that innovation itself increases
the need for an organizational framework able to cope with new problems as they
appear during the innovation process.
The aim of a learning healthcare organization is to deliver the best care every time, and
to learn and improve continuously. Organizational changes could contribute to a
learning healthcare organization that supports continuous learning and knowledge
creation as a natural by-product of health care delivery. A fully functional system of this
sort would deliver increasing value to the health services’ user through innovation.
According to the response pattern of major aims for innovation, most hospitals are
obviously aiming at efficiency and organizational flexibility.The distribution of
organizational capacities to innovate and develop new knowledge reveals significant
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differences between hospitals. Knowledge as a reason for organization innovation is
seen by a third of hospitals as high, while the others see it as of low (one third) or
moderate (one third) importance. The distribution of opinions by the hospital’s
Administration Boards reveals three different ways of looking at knowledge within the
organization. In fact, the relevance attribute different ways of thinking might influence
the organization of hospitals towards a “learning organization”. Therefore, the paper
further makes a more detailed analysis of the three different groups of hospitals based
on the degree of learning organization in order to bring relevant insights in learning
dynamics and its contributions for innovation.
Clusters of learning organizations
The cluster analysis by organizational changes points out the distinguishing
characteristics of learning organizations and their relationship with innovation and
performance. It has to be underlined that the number of organizations in each group is
dependent upon the chosen criteria. Therefore, the different terms of basic, moderate
and advanced learning organizations have to be understood within the limits defined by
its operationalization.
The “basic learning organizations” are marked by managerial hierarchies, with a clear
division of functions and tasks. Within this context, health professionals are performing
well defined functions, which are controlled by several layers of managers. Such control
mechanisms rely on highly standardized procedures. This points to a more structured or
bureaucratic style of organization, with the lowest level of innovation and performance,
with a mean of 1.6 (2.3) and 4.8 (1.9), respectively.
The “moderate learning organizations” have statistically significant higher levels of
organizational flexibility. However, learning can be constrained and isolated into one
19
department, while the rest of the organization remains bureaucratic. The impact of
learning mechanisms already in place might explain a significant higher level of
innovation and performance in comparison to the former cluster, with respectively a
mean of 3.91 ( 3.7) and 7. 6 (4.1).
The cluster of “advanced learning organizations” is characterized by high levels of
learning and problem solving in work teams. Such a learning environment is widely
spread across the different departments. This group, combining several characteristics of
learning organizations tends to show higher capacity for innovation and performance
than the rest, with a mean of 6.9 (3.2) and 9.3 (6.0), respectively. The “advanced
learning organizations”might beparticularlyinstructive to other hospitals by revealing
the main mechanisms for integrating research and practice, as well as, for translating
external research findings into practice.
Flexibility and external cooperation
The major variables distinguishing the three clusters are those indicators capturing
conditions for enhancing learning including self-assessment of work quality, quality
standards, cross-department collaboration, external cooperation, team work, work task
allocation and rotation. The cluster of “advanced learning organizations” shows a wider
use of organizational changes towards enhancing learning across the hospital, compared
to “moderate learning organizations”. The cluster of “basic learning
organizations”shows a residual use of these organizational changes, reflecting a less
conducive environment towards learning.
The three clusters of hospitals reveal significant differences in terms of organizational
structure and processes, management style and skills development. As the horizontal
and vertical division of labour evolves, it contributes to the necessary diversity feeding
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innovation. However, it also creates new barriers for communication and interaction
within the hospital and with other organizations. This is highly relevant because
innovation is the outcome of combining knowledge located at different sites.
Organizational flexibility and external cooperation are the two major discriminating
factors explaining differences in terms of innovation and performance across the three
clusters of hospitals.
The results from this research bring implications for management in the health sector.
Management needs to enhance a supportive environment for learning, creating room for
human resources development as well as, work team and cross-department
collaboration. While management cannot force renewal, it can support an environment
for radical renewal through wide internal networks across departments and divisions.
This is a requisite for continuous learning. It is well documented that different
departments within a hospital have difficulties to understand and communicate with
each other. Increasing this internal capability is also a prerequisite for effectively
assimilating and applying knowledge from outside.
Furthermore, the recent models of innovation particularly emphasize learning as an
interactive process in which hospitals interact with other organizations, including
suppliers and universities. This is also the background for developing a systemic
approach to knowledge creation. A wide external cooperation has the potential to create
opportunities to access new knowledge for further development of innovations. Results
suggest that integration of service delivery systems might expand capacity for real-time
learning in daily practice.
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The impact of learning organizations on innovation development
Summing up, the model examined in this paper has shown significant effects of the
development of the so called “learning organization” on innovation. This strongly
supports the validity of theoretical considerations regarding the construct of “learning
organization”. It illustrates that hospitals combining quality control, human resources
development and external cooperation are much more prone to innovate.
The proposed measures set the way to systematically capture and translate information
generated by clinical research and health care delivery by promoting close open-ended
learning loops.As noted in the results, the supply of knowledge currently available to
hospitals has several deficiencies. Hospitals often lack reliable evidence on the
effectiveness of different treatment options, interventions, and technologies and on how
the effectiveness of treatments varies for different patients. Moreover, the quality of
care depends not only on the effectiveness of a given treatment but also on the way that
treatment is delivered. Thus, it is necessary to build knowledge about different methods
of delivering care and provide hospitals with tools to improve care processes. Learning
processes must also be tailored to the circumstances and needs of hospitals and other
stakeholders in the health system. Each stakeholder has a different role in the generation
and dissemination of knowledge, so each will need different tools to support continuous
learning and improvement. Furthermore, the learning potential of hospitals and their
cooperation partners might be significantly enhanced by the new opportunities provided
by ICT to share information and measure progress.
6. CONCLUSIONS
The primary result is the distinction of different types of “learning organizations” in the
Portuguese hospital sector, which has not before been covered in this way. Furthermore,
22
the paper reveals the mutually reinforcing interrelationship between innovation and
learning processes.
The study concludes that hospitals pursuing strategies of innovation realize the
relevance of enhancing a learning organization. Suchan approach suggests that the key
role of hospitals for the creation, transfer and application of knowledge for innovation
development. Indeed, a mismatch between the hospital’s knowledge and innovation
domains might favour external collaboration in order to get the right match of
knowledge. Therefore, the analytical framework of learning organizations goes beyond
the hospital to include the external cooperation network, as well asthe way they
exchange knowledge between each other.
In conclusion, the paper proposes a wider perspective to innovation development in
hospitals in order to focus on the knowledge infrastructure. Such infrastructure would
include both individual and organisational learning towards enhancing innovation. Due
to the complexity of the Portuguese National Health Service, it cannot, as a whole
system, become a learning organisation. However, it is possible that hospitals may
achieve this status to varying degrees. In fact, as more hospitals become exposed to the
need to engage on innovation development, there is increasing potential for learning
dimensions to be reflected in organizational strategies and public policies. Such a trend
would bring higher priority to policies aiming at human resource development,
developing new forms of organisations and creating external cooperation networks.
The major implication arising from this study is that policy needs to combine
instruments that promote innovation opportunities and incentives, with instruments
stimulating the further development and diffusion of the core components of learning
organizations. Such a combination of policy instruments has the potential to ensure a
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wide external cooperation and bring together different organizations through a learning
infrastructure.
The paper also reflects a shift from a static to a more dynamic model of learning
organizations in terms of innovation policies. It recognizes the nonlinear and interactive
nature of learning through the development of innovations adapted to local health needs
and assets. In this context, hospital services would go from “silo” to “systems” thinking,
enhancing the delivery of health services based on update evidence and wide
communication among the main stakeholders. Drawing from current results, the study
proposes several policy solutions: First, support a culture renewal that encourages
problem-solving in new ways across the whole organization; second, emphasize the
links between elements of the hospital care and administrative processes. Both measures
are crucial for effective health care models and new communication systems to provide
the accurate, timely transfer of information throughout the healthcare continuum. Third,
continuous learning and health care improvement requires transparency in processes and
outcomes as well as the capacity to capture feedback and make adjustments. Finally,
there is also the need to align rewards on the key elements of continuous learning and
improvement of health care performance, across the different stakeholders. In fact,
incentives, standards, and measurement requirements can serve as powerful change
agents and are key elements of the policy framework for innovation development in the
hospital sector.